Michael Kamali

Emergency department waiting room: many requests, many insured and many primary care physician referrals

BackgroundIncrease in waiting time often results in patients leaving the emergency department (ED) without being seen, ultimately decreasing patient satisfaction. We surveyed low-acuity patients in the ED waiting room to understand their preferences and expectations.MethodsAn IRB approved, 42-item survey was administered to 400 adult patients waiting in the ED waiting room for >15 min from April to August 2010. Demographics, visit reasons, triage and waiting room facility preferences were collected.ResultsThe mean age of patients was 38.9 years (SD = 14.8), and 52.5% were females. About 53.8% of patients were employed, 79.4% had access to a primary care physician (PCP), and 17% did not have any medical insurance. The most common complaint was pain. A total of 44.4% respondents reported that they believed their problems were urgent and required immediate attention, prompting them to come to the ED, while 14.6% reported that they could not get a timely PCP appointment, and 42.9% were actually referred by their PCP to come to the ED. About 57.7% of patients considered leaving the ED if the waiting times were too long. The mean acceptable waiting time before leaving ED was 221 min (SD = 194; median 180 min, IQR 120–270). A total of 39.1% survey respondents reported being most comfortable being triaged by a physician. Respondents were least comfortable being triaged by residents. On analyzing waiting room expectations for the survey respondents, we found that 70% of the subjects wanted a better estimate of waiting time and 43.5% wanted better information on reasons for the long wait.ConclusionContrary to popular belief, at our ED a large proportion of low-acuity patients has a PCP and is medically insured. Providing patients with appropriate reasons for the wait, an accurate estimate of waiting time and creating separate areas to examine minor illness/injuries would increase patient satisfaction within our population subset.

The initial lateral cervical spine film for the athlete with a suspected neck injury: helmet and shoulder pads on or off?

Plain radiographs remain the only reliable way to exclude cervical spine derangement during the initial Emergency Department (ED) evaluation of the athlete with a suspected neck injury. There have been no studies to evaluate whether the cervical spine can be adequately visualized when a helmet and shoulder pads remain on while the lateral cervical spine scout film is done in the ED trauma suite. The objective of our investigation was to determine whether a helmet and shoulder pads interfere with the assessment of the cervical spine on this initial ED radiographic evaluation.

Rhabdomyolysis associated with kava ingestion.

We report a case of rhabdomyolysis temporally related to the ingestion of a large amount of kava. Kava is a naturally occurring plant used in the United States and elsewhere in the world for its sedative properties. A previous case report also related rhabdomyolysis to the ingestion of kava. It is not clear whether this is an action of the kava itself, perhaps, due to its action on voltage ion channels or, perhaps, due to an adulterant in the product. Our patient developed peak creatine phosphokinase levels in excess of 30 000 U/L but had no significant renal damage.

Acute encephalopathy with concurrent respiratory and metabolic disturbances in first known parenteral human administration of flunixin meglumine and acepromazine maleate.

BACKGROUND Flunexin is a nonsteroidal anti-inflammatory drug approved for veterinary use in horses and cattle. Acepromazine is a phenothiazine derivative used in horses, dogs, and cats. Human exposure to these substances is rare. CASE REPORT We report a case of a human injection of two equine medications, flunixin and acepromazine, which resulted in altered mental status, respiratory alkalosis, gastrointestinal bleeding, and elevation of liver transaminases in a 43-year-old woman who worked as a horse trainer. The patient intentionally self-injected these medications and subsequently presented to the Emergency Department with altered mental status and lethargy. The patient required hospitalization for metabolic abnormalities, including respiratory alkalosis, and suffered a gastrointestinal bleed requiring blood transfusion. The patient ultimately recovered with supportive measures. We believe this to be the first case of concomitant injection of flunixin and acepromazine in a human. CONCLUSIONS This report explains a case of parenteral administration of two equine medications and the subsequent complications in a patient that presented to the Emergency Department. Human exposure to veterinary medications cannot be predicted by their effect in animals due to variations in absorption, distribution, and metabolism. Physicians should be aware that individuals who work with animals may have access to large quantities of veterinary medicine. This case also exemplifies the challenges that Emergency Physicians face on a daily basis, and generates additional consideration for overdoses and intoxications from medications that are not considered commonplace in humans.

Pregabalin and paradoxical reaction of seizures in a large overdose

ABSTRACT We report the case of a 54-year-old female with intentional pregabalin 3825 mg ingestion that resulted in a rare adverse effect of a witnessed seizure with confirmatory serum concentrations. After presenting alert to the emergency department she became obtunded, only responding to sternal rub (four hours after ingestion). Laboratory evaluation and toxicology panel were unremarkable. Approximately eight hours after the ingestion she had physician-witnessed tonic–clonic seizure activity with right gaze deviation for 90 seconds. This is only the third documented case of paradoxical seizure due to a large overdose of pregabalin. Also, the serum concentration observed is among the highest recorded (58 mcg/mL five hours post-ingestion). Pregabalin abuse has been emerging. Clinical toxicologists should be aware of the potential of pregabalin-induced seizures following overdose.

Analysis of Triage Systems in Emergency Departments

In this paper we study triage decisions in emergency departments. In particular, we provide a policy for determining when to apply provider triage (PT) based on operational and financial considerations using a queueing framework. We obtain closed-form expressions for the range of arrival rates in which PT economically outperforms traditional nurse triage using a steady-state many-server fluid approximation. We show that the proposed solution methodology based on this approximation procedure is asymptotically optimal under a many-server asymptotic regime. Using patient data from a large teaching hospital, we show via simulation experiments that the proposed policy performs within 0.82% of the best solution given by a computationally intensive total enumeration method.